Smith, Martha NEW YORK STATE DEPARTMENT OF HEALTH - �i -
Vital Records Section Burial - Transit Permit
i
Name First Middle Last Sex
`0{ Martha J. Smith Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 24,2015 98 War or Dates 1943- 1945
Place of Death Hospital, Institution or
City, Town or Village Corinth Street Address 208 Center Street
Manner of Death n Natural Cause n Accident n Homicide n Suicide 1-1 Undeterminedn Pending
Circumstances Investigation
Medical Certifier Name Title
PO
Amy Johnson,RPA
z
A
Address
W 13 Palmer Ave.,Corinth,NY 12822
le Death Certificate Filed District Number Register Number
rid City, Town or Village Corinth
❑Burial Date Cemetery or Crematory
September 28, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
NLi Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
- Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
CO Address
407 Bay Road, Queensbury, NY 12804
,, , Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
,t Permission is her by gr nted to dispose of the huma emains describ bove s i 'cated.
Date Issued q S` /1 Registrar of Vaal Statistics
nature)
%, District NumberA-g3 Place L�z�• i
I certify that the remains of the decedent identified above were dis sednnof in accordance with this permit on:
tu Date of Disposition jo/j/lc Place of Disposition 4?, l) (e#0"4orw1...
(address)
W
N
ft
0 (section) %//� (lot number (grave number)
pName of Sexton or Person in Charge of Premises Lit*" 3t«wl►t
Z I (please print)
WL Signature Title itut. •
(over)
DOH-1555(02/2004)